Introduction
The COVID-19 pandemic and Black Lives Matter (BLM) movement brought to light the longstanding social injustices that exist within society. Racially-minoritised (non-White) people have been disproportionately affected by COVID-19, with an increased risk of dying from the virus (Williamson et al., Reference Williamson, Walker, Krishnan, Bacon, Bates, Morton, Curtis, Mehrkar, Evans, Inglesby, Cockburn, McDonald, MacKenna, Tomlinson, Douglas, Rentsch, Mathur, Wong, Grieve, Harrison, Forbes, Schultze, Croker, Parry, Hester, Harper, Perera, Evans, Smeeth and Goldacre2020). Within the UK, there are mental health needs of diverse racially-minoritised communities, who are not being represented within primary care Talking Therapies services (previously known as IAPT: Improving Access to Psychological Therapies) (NHS Digital, 2020) but also within clinical psychology training (Clearing House for Postgraduate Courses in Clinical Psychology, 2020). This has generated the essential conversation and need for action in tackling systemic racism and inequalities within the NHS and healthcare provision.
Terminology and position
The primary researcher (S.A.) positions themselves as a British-Bangladeshi Muslim male trainee clinical psychologist in London, UK, at the time of writing this review. Much of the current UK research has used the terms ‘BAME’ (Black, Asian and Minority Ethnic), ‘minority’ or ‘ethnic’ so these terms have been used during the systematic review process. However, these terms are currently not universally accepted (Milner and Jumbe, Reference Milner and Jumbe2020) and other terms such as ‘global majority’ or ‘racially-minoritised’ are (Lawton et al., Reference Lawton, McRae and Gordon2021). S.A. uses the term ‘racially-minoritised’ to acknowledge how people are actively minoritised by others as a social process shaped by power, rather than naturally existing as a minority (Predelli et al., Reference Predelli, Halsaa, Thun and Sandu2012).
Healthcare needs of racially-minoritised communities
In the UK, racially-minoritised people are more likely to have poorer health outcomes, greater mortality and greater difficulties with accessing healthcare (Raleigh and Holmes, Reference Raleigh and Holmes2021). People face individual and societal adversity such as racism, discrimination, and social and economic inequalities, which all have a major impact on mental health (Gibbons et al., Reference Gibbons, O’Hara, Stock, Gerrard, Weng and Wills2012). Individuals are likely to experience poverty, poorer educational outcomes, higher unemployment and contact with the criminal justice system, which are all risk factors to mental health difficulties (Equality and Human Rights Commission, 2016). Shade (Reference Shade2021) highlights how the way society is organised creates huge amounts of distress, and tackling these issues must not be only at an individual level; the discussion regarding health inequalities must also be a political one.
The historical and current societal context must be considered as mental health systems for marginalised groups can be oppressive and racially biased. For example, the American Psychiatric Association (APA) had upheld racist beliefs such as Black people being primitive and hostile and in 2021, they issued an apology (American Psychiatric Association, 2021). Black people are at increased risk of common mental health difficulties but are also more likely to receive pharmacological treatment and detention than psychological therapy (Lawton et al., Reference Lawton, McRae and Gordon2021). Continually, racially-minoritised people have been put in a position of disadvantage, with health inequalities being perpetuated by racism and discrimination in society, which also plays out within healthcare itself.
Mental health is not just a ‘White problem’ as needs are evident within racially-minoritised people. For example, suicide rates are higher among young Black African and Caribbean men, middle-aged Black African and Caribbean women, and South Asian women compared with the White population (Bhui and McKenzie, Reference Bhui and McKenzie2008). NHS Digital (2020) highlight in their annual report on the use of Talking Therapies services in England how fewer racially-minoritised people are referred to Talking Therapies services compared with the White British population. Therefore, there are mental health needs of racially-minoritised people, with clear disparities in access to early intervention, such as primary care mental health support.
Barriers to accessing mental health support
Racially-minoritised communities are less likely than White people to have contacted their General Practitioner (GP) about mental health difficulties, to be prescribed medication or be referred onto specialist mental health services (Morgan et al., Reference Morgan, Mallett, Hutchinson, Bagalkote, Morgan, Fearon, Dazzan, Boydell, McKenzie, Harrison, Murray, Jones, Craig, Leff and Study Group2005). This highlights how a barrier to accessing mental health support for minoritised communities could be that services are not being considered by GPs. Furthermore, there may be reasons why people do not speak to GPs about mental health difficulties, such as self-stigma and confidentiality concerns, which indicate internal and external barriers to accessing support (Edge, Reference Edge2008).
Memon et al. (Reference Memon, Taylor, Mohebati, Sundin, Cooper, Scanlon and De Visser2016) state how there is little research into understanding the barriers that racially-minoritised people face when accessing mental health services in the UK. Therefore, they set out to research this qualitatively to inform the development and commissioning of effective and culturally competent services. Results identified barriers such as an inability to recognise and accept mental health problems, reluctance to discuss distress and seek help, identity, stigma and the positive impacts of social networks. They also found factors such as language barriers, long waiting times, imbalance of power, cultural naivety, and discrimination. This led to racially-minoritised people feeling misunderstood and less confident that services could adequately meet their needs. To overcome these barriers, suggestions included improved service access pathways, training for healthcare providers in culturally sensitive care, and improved engagement with racially-minoritised people within service development.
The Scottish Psychological Therapies Matrix (NHS Education for Scotland 2023), Welsh Matrics Cymru (NHS Wales, 2017) and the Strategy in Northern Ireland (Department of Health, 2010) all focus on equitable access to psychological therapies in these regions of the UK. The National Institute for Health and Care Excellence (NICE, 2018) in England highlight how racially-minoritised communities are less likely to access mental health treatment, which could be associated with stigma but also accessibility. Services must be visible, accessible and responsive to the needs of communities. Talking Therapies services have aimed to increase the availability of NICE-recommended psychological therapies in the NHS (Beck, Reference Beck2019). However, racially-minoritised communities have been under-represented in services, with poorer outcomes (Baker, Reference Baker2018). In the 2020 briefing paper (Baker, Reference Baker2020) it is continued to be reported that racially-minoritised people are still under-represented in Talking Therapies services, for example Asian British people are 14% less likely than the White British population to be in contact with services. Begum (Reference Begum2006) states how racially-minoritised communities are traditionally seen as ‘hard to reach’, but there are key barriers that must be addressed rather than using this label.
NHS Race and Health Observatory (2023) published a report of ethnic inequalities in access, outcomes and experience for people who engage or try to engage with NHS Talking Therapies services. Progress and improved outcomes for some racially-minoritised groups are reported, but with continued inequalities between groups, including intersectional differences considering gender, age and socioeconomic status. Access, outcomes and the experience of Talking Therapies must improve for racially-minoritised people, especially for the Bangladeshi population who have some of the lowest outcomes [see Alam (Reference Alam2023) for further research within the Bangladeshi population]. The report suggested that those in leadership positions within mental health services should focus on understanding the needs of communities, looking at resources and funding. Recommendations are made such as continued recording and use of local data on access and outcomes, implementing the BAME Positive Practice GuideFootnote 1 (Beck et al., Reference Beck, Naz, Brooks and Jankowska2019), services meeting the aims of the Patient and Carer Race Equality FrameworkFootnote 2 (NHS England, 2023) and recruiting, training and retaining a diverse and skilled workforce.
Harwood et al. (Reference Harwood, Rhead, Chui, Bakolis, Connor, Gazard, Hall, MacCrimmon, Rimes, Woodhead and Hatch2023) researched into the variations by ethnicity in referral and treatment pathways for Talking Therapy service users in South London between 2013 and 2016. They found that compared with the White British population, Black African, Asian, and mixed ethnic groups were less likely to self-refer. This may be due to invalidating experiences when being told by a GP to self-refer, after building up courage to speak. Black Caribbean, Black Other and White Other groups were more likely to be referred through community services and most racially-minoritised groups were less likely to receive an assessment and to be treated. Potential reasons suggested are due to stigma, fear and shame, but also discriminatory structures and attitudes within mental health services. This highlights how barriers exist at different stages on a pathway to accessing therapy and more must be done to address these. IAPT Workers Café (2023) had written a letter calling on NHS England to develop and implement tangible anti-racist initiatives in Talking Therapies services, where they emphasise the need for services to improve access and equity of outcomes, with the suggestion to incentivise services to do better. Overall, there are gaps within services and disparities that exist, with continued work needed to improve access, outcomes, and the experiences of racially-minoritised populations.
Systematic review
There is no existing systematic review which aims to understand the barriers to mental health support for racially-minoritised people within the UK. This systematic review is not a comparison to the White British population, rather it hopes to amplify the voices, views and experiences of racially-minoritised people. This review was registered in September 2020 on the international prospective register of systematic reviews in health and social care (PROSPERO).
Mental health services within the UK specifically aim to improve access to psychological therapies, although there are mental health needs of racially-minoritised people that could be better met (Faheem, Reference Faheem2023). This review broadly looks at barriers to varying levels of mental health support (primary and secondary care), due to the lack of research in this area. This review has the potential to help inform initiatives for services and professionals to improve accessibility of mental health services, which include Talking Therapies by exploring and highlighting the experiences of racially-minoritised people. This is essential to appropriately support communities who have greater need, considering the societal and contextual issues which put racially-minoritised people at risk of developing mental health difficulties (Shade, Reference Shade2021). This would also be in line with the NHS ethos and values to reduce health inequalities (NHS Digital, 2020).
Method
This systematic review looked at qualitative papers related to the research question: What are the barriers to mental health support for racially-minoritised people within the UK?
Qualitative papers only were used to explore the experienced barriers of racially-minoritised people within the studies. The method was informed by Boland et al.’s (Reference Boland, Cherry and Dickson2017) guidance on undertaking systematic reviews for students and reporting follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., Reference Moher, Liberati, Tetzlaff, Altman and PRISMA2009). The thematic synthesis methodology was adapted from that described by Thomas and Harden (Reference Thomas and Harden2008). See Table 1 for inclusion and exclusion criteria for the review.
Table 1. Inclusion and exclusion criteria for systematic review
Search strategy and selection criteria
Qualitative studies were searched for using two main databases: PsycINFO and Web of Science. Search terms were also reviewed to consider variations of the term ‘ethnic’ used within UK research. Final search terms are given in Table 2.
Table 2. Search terms used for PsycINFO and Web of Science databases to identify eligible papers
Additional papers
Reference mining was done by searching references of papers by Alhomaizi et al. (Reference Alhomaizi, Alsaidi, Moalie, Muradwij, Borba and Lincoln2018), Mantovani et al. (Reference Mantovani, Pizzolati and Edge2016) and Shefer et al. (Reference Shefer, Rose, Nellums, Thornicroft, Henderson and Evans-Lacko2013), which were found from initial database searches. The main researcher was also familiar with these additional papers from the development of an empirical study (Alam, Reference Alam2023). The researchers agreed that these papers related to barriers to mental health support involving racially-minoritised people. Three additional papers by Arday (Reference Arday2018), Memon et al. (Reference Memon, Taylor, Mohebati, Sundin, Cooper, Scanlon and De Visser2016) and Robinson et al. (Reference Robinson, Keating and Robertson2011) were found through Google Scholar, which were also relevant to the research question.
To account for the risk of bias, the primary researcher (S.A.) and an assistant psychologist (S.O’H.) screened all titles and abstracts. Independent searches were then compared to give an initial list of studies. The selection criteria were reviewed and if the citation matched, the full paper was obtained. Full papers were screened independently by the two researchers. Any disagreements were discussed, with arbitration available from the research supervisor (A.F.). Quality of the included studies was assessed using the Critical Appraisal Skills Programme (CASP) tool for reviewing qualitative studies (Critical Appraisal Skills Programme, 2018). This process is illustrated in Figure 1.
Figure 1. PRISMA flow diagram summarising the stages in eligibility screening from the database searches (Moher et al., Reference Moher, Liberati, Tetzlaff, Altman and PRISMA2009).
Quality assessment
Reporting on the quality appraisal of the studies was done using the CASP checklist (Critical Appraisal Skills Programme, 2018). Criticisms of the CASP tool are that it can be less sensitive and valid as a measure of methodological quality compared with other tools such as the Evaluation Tool for Qualitative Studies (ETQS) and the Joanna Briggs Institute (JBI) tool (Hannes et al., Reference Hannes, Lockwood and Pearson2010). However, the CASP tool is a commonly used quality appraisal checklist in health and social care-related qualitative evidence syntheses and is endorsed by Cochrane and the World Health Organisation for use in qualitative evidence synthesis. This uses 10 questions to evaluate qualitative research, being suitable for use by new researchers (Hannes and Macaitis, Reference Hannes and Macaitis2012). Each paper was rated independently by each researcher (S.A. and S.O’H.) and the scores were compared, to check inter-rater reliability. There was agreement between both researchers on the CASP score for each research paper.
The decision was to include all identified studies, regardless of quality, as initial searches indicated relatively few research papers. This allows the chance to observe all potential valuable insights (Thomas and Harden, Reference Thomas and Harden2008). The details of each study including the agreed CASP ratings can be found within the Results section (see Table 3).
Table 3. Characteristics and context of the 15 eligible studies included for the systematic review
The term ‘BAME’ is included here due to its use within the individual studies. The location within the UK is not stated for some studies, as this was not specified.
Data extraction and thematic synthesis
Thematic synthesis was used to bring together findings from the included studies and draw conclusions. Cruzes and Dybå (Reference Cruzes and Dybå2011) state how this approach draws on principles of thematic analysis to identify recurring themes in multiple studies, by interpreting, explaining, and drawing conclusions in systematic reviews. There are limitations of this approach such as it being subjective and individual studies being de-contextualised (Thomas and Harden, Reference Thomas and Harden2008). However, summaries of studies provide context (see Table 3) and a second researcher (S.O’H.) was used throughout.
The thematic synthesis process
The process used a transparent research trail, noting the decisions made, using two researchers (S.A. and S.O’H.) and a researcher supervisor (A.F.), considering researcher bias and opening the data to a broader range of possible interpretations (Noyes et al., Reference Noyes, Popay, Pearson, Hannes, Booth, Harris, Harden, Pearson, Cargo and Pantoja2001). The researchers worked together on the systematic review between January 2021 and April 2021. The steps for thematic synthesis following Thomas and Harden (Reference Thomas and Harden2008) are as follows:
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(1) Free line-by-line coding of the findings in primary studies. The researchers independently reviewed each paper, extracting 233 quotes and meeting to agree on codes. There were 44 initial codes from the 15 papers.
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(2) Organisation of these ‘free codes’ into related areas to construct ‘descriptive themes’. The researchers looked for similarities and differences between codes, which helped group them into a map (which can be found in the Supplementary material). This was to see what the codes were describing, which gave a total of 13 descriptive themes.
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(3) Development of ‘analytical themes’. The researchers independently generated analytic themes, to then discuss and jointly agree on four final themes, in the context of the review question. Themes were finally compared with the original quotes to ensure the thematic framework was suitable.
Results
The systematic review found 15 relevant studies, which include racially-minoritised people within the UK. Characteristics of the studies are shown in Table 3, including the aim of the study, sample characteristics, data collection methodology, analysis, findings, how trustworthiness was ensured, and agreed CASP ratings.
Participant characteristics
The review searched for papers covering the UK; however, the papers found were all with racially-minoritised people in different regions of England only and some papers did not specify. This highlights the lack of research in other nations such as Scotland, Wales and Northern Ireland. Additionally, this may reflect a lack of centralised data in these parts of the UK, where there may also be poor access and outcomes to therapy. The Republic of Ireland was not included as it is not within the UK and a sovereign country.
There is a lack of specificity in the reporting of identity. Some research papers specify the ethnicity of the participants, whereas others use fewer specific terms. Ethnic groups identified are Black Caribbean (Edge, Reference Edge2008), Pakistani (Gunasinghe et al., Reference Gunasinghe, Hatch and Lawrence2019), Somali (Rae, Reference Rae2016), Indian, Bangladeshi and Chinese (Robinson et al., Reference Robinson, Keating and Robertson2011). Other studies used broader terms to describe participants such as African (Mantovani et al., Reference Mantovani, Pizzolati and Edge2016), South Asian, Latin American or Mixed Heritage (Arday, Reference Arday2018). Participants ranged from students (Arday, Reference Arday2018; Sancho and Larkin, Reference Sancho and Larkin2020), service users (Edge, Reference Edge2008), people in the community (Gunasinghe et al., Reference Gunasinghe, Hatch and Lawrence2019) and a mix with people from voluntary sector organisations, commissioners, professionals (Islam et al., Reference Islam, Rabiee and Singh2015) and faith leaders (Mantovani et al., Reference Mantovani, Pizzolati and Edge2016). Ages ranged from 18 to 65 years old with both men and women used in the sample, from different religions such as Islam (Gunasinghe et al., Reference Gunasinghe, Hatch and Lawrence2019) and Christianity (Mantovani et al., Reference Mantovani, Pizzolati and Edge2016). Socioeconomic status or sexuality is not recorded for the majority of the studies, so this is not reported here.
Quality appraisal
The CASP checklist (Critical Appraisal Skills Programme, 2018) does not have pre-determined cut-off points to indicate if a study has good quality; it is up to the researchers to decide. The majority of the 15 papers rated well on the CASP checklist, with all of them scoring 6 or more. The average score for the papers was meeting 8 out of the 10 criteria, which the researchers agreed indicated a very good quality of the studies used on the 0–10 rating scale. Lower numbers indicated studies with lower quality, with 6 or 7 being good, and 8 and above indicating very good quality. Studies scoring below 5 would have been studies rated as having poorer quality.
Themes
Using thematic synthesis, the researchers (S.A. and S.O’H.) identified 13 descriptive themes and four final analytical themes, which are ‘internal and external stigma’, ‘understanding of distress and coping’, ‘competence of professionals and services’ and ‘perception and accessibility’. Barriers can be thought about at the individual, practitioner, team, and access level. Information highlighting the contribution of each of the 15 papers to each theme can be found in the Supplementary material, and additional quotations can be found in the Appendix.
1. Internal and external stigma
Descriptive themes: ‘perception of self’ and ‘consequences’
Racially-minoritised people within the studies reported stigma as a barrier to accessing formal mental health support, as a participant stated ‘I think there’s a stigma as well about failure and not being able to cope. The word depression, it’s got such negative connotations so perhaps that actually keeps us from going to ask for help’ (Edge, Reference Edge2008; p. 386). People reported self-stigma in the form of being ‘weak’, feeling like a failure and this being shameful. One participant said: ‘Sometimes that’s why they [racially-minoritised people] don’t seek help early enough because they feel ashamed, they feel it is a weakness, they have to hide it: we mustn’t tell the family, we mustn’t tell the community. The parents will be blamed’ (Shefer et al., Reference Shefer, Rose, Nellums, Thornicroft, Henderson and Evans-Lacko2013; p. 359).
Disclosure was seen to have negative consequences, such as becoming isolated from the community or family. It is not the cultural ‘norm’ to access formal support from services, as a South Asian female participant states: ‘[South Asian women would be] scared of people finding out about the situation because if found out they would be shunned upon by the Asian community … People would not see it as a norm to go to a counsellor, therefore even if they wanted to, they wouldn’t’ (Moller et al., Reference Moller, Burgess and Jogiyat2016; p. 207).
People can see themselves as ‘weak’, fearing negative judgement and losing social support as consequences. Stigma seems to present internally for individuals but also externally from other people, with stigma related to experiencing mental health difficulties but also accessing help, which could stop someone from accessing support.
2. Understanding of distress and coping
Descriptive themes: ‘understanding of mental distress’, ‘spirituality’, ‘managing problems within the system’ and ‘expectations within culture’
Racially-minoritised participants show how mental health is understood differently compared with the White Western population. Findings suggest how mental health is seen as not as serious as physical health, with a South Asian male saying, ‘someone who has diabetes something like that is more severe and they need to go to a doctor. Someone who has anorexia, sort it out yourself’ (Wales et al., Reference Wales, Brewin, Raghavan and Arcelus2017; p. 11).
Mental health is understood considering the lens of religion and culture, with spiritual coping methods being an early source for support. A Somalian male states, ‘the Quran [religious text in Islam] will kill this kind of things … Evil eye [misfortune from another’s jealousy or envy] and all this. So yes, spiritual is very important factor’ (Rae, Reference Rae2016; p. 66).
Problems tend to be kept to oneself or within the family, which could delay help-seeking from formal services, as alternative sources of help are relied on such as religion and family: ‘In the West Indian community … people do not trust psychiatrists particularly … in terms of where my family and friends would turn in experiences of bad mental health or whatever is towards family structures. Informal structures, friends’ (Arday, Reference Arday2018; p. 13).
From the studies reviewed, findings show differences between men and women, with men not talking about their emotions; culturally expected to be ‘strong’ and manage themselves: ‘Society accepts the woman being more emotional than men … it’s erm amplified in the Afro-Caribbean society as well because now you’re adding that in general … Afro-Caribbean people are meant to be strong, but now – Afro-Caribbean men it’s even 10 times worse. Cos a lot of the time they don’t talk about their emotions or feelings so having them admit it is even harder I feel’ (Sancho and Larkin, Reference Sancho and Larkin2020; p. 72).
Intersectionality must be considered, as everyone has their own understanding of mental distress, considering age, gender, culture, religion, and other aspects of identity. Assumptions should be avoided, and individual factors acknowledged, explored and understood which impact understanding of mental health, access to services and outcomes.
3. Competence of professionals and services
Descriptive themes: ‘diversity’, ‘discrimination’, ‘need for understanding’ and ‘negative experiences’
From the studies reviewed, the perceived competence of services and professionals is a barrier to racially-minoritised people accessing formal support. There tends to be limited choice and less diversity within services, as an Indian male participant states: ‘for men there have been no Asian male counsellors, no specific support scheme’ (Robinson et al., Reference Robinson, Keating and Robertson2011; p. 87). A man of mixed heritage also states, ‘to be honest, it would just be nice to speak to a person that looked like you … who can relate to you culturally and understand what you are experiencing as a person of colour’ (Arday, Reference Arday2018; p. 15). Some people prefer to see someone from their own culture, others not, but at least wanting this option as a South Asian woman states: ‘it all depends on the situation. If it was something that was stigmatised in my culture, then I would definitely go to a White person’ (Moller et al., Reference Moller, Burgess and Jogiyat2016; p. 206)’
Racially-minoritised people within the research reported to have negative experiences of professionals and experienced discrimination from services, considering power imbalances, fearing judgement from those professionals holding power. A participant states: ‘I got an English friend and she said to me that she has got the same problem … her GP transferred her to her consultant to see her problem and her problem was solved. Why would my GP not transfer me to a consultant instead of giving me a different tablet every time? I just feel like I am really angry and really frustrated because they transferred her because she is English and I am not English’ (Memon et al., Reference Memon, Taylor, Mohebati, Sundin, Cooper, Scanlon and De Visser2016; p. 6).
There was a need for understanding of people from racially-minoritised groups, as it was often felt that professionals would misunderstand or not hear what the person was saying, with a feeling that this was not taken seriously. A Muslim Pakistani man states: ‘we can’t blame them because they’re upbringing is like Westernised, they can’t understand if we talk about Jinns [evil spirits] …’ (Islam et al., Reference Islam, Rabiee and Singh2015; p. 747). Services must address their internal structures and systems in how competent they are in working with diverse populations, being aware of their own biases and how this can impact their interaction with service users: ‘The staff that manage these services have to be culturally aware and not have their hang-ups. A lot of them come in with their baggage and they’re not leaving it at the door. They practise it every day. They see – if there’s a mental health patient who is big, a big Black man, six-foot two, somehow they are afraid of him more than a six-foot, seven-foot, White man’ (Mclean et al., Reference Mclean, Campbell and Cornish2003; p. 664).
Findings also highlighted there being less diversity in the promotion of therapy in the media and how services lack meeting the needs of racially-minoritised people: ‘And I think if they tried to use more Afro-Caribbean men, women, dark skin men, women and start to use people that actually look like us in their sort of media representation then they can maybe see it as this issue isn’t just a Caucasian – it’s not a White issue it – it’s an issue that can affect anyone’ (Sancho and Larkin, Reference Sancho and Larkin2020; p. 74).
4. Perception and accessibility
Descriptive themes: ‘access to appropriate help’, ‘practical barriers to help’ and ‘trust’
Professionals must consider if services are visible, accessible, and how they are perceived. When talking about her community, a female participant reports: ‘it’s not that they don’t want to access the service, it’s just they don’t even know about the services. They’re not aware of it for one’ (Islam et al., Reference Islam, Rabiee and Singh2015; p. 745). ‘It could be a good service. It could be a brilliant service. Perception is key. If I perceive, if the community perceives that the facility is not really sensitive to me or geared to my needs, no matter how good it is, I ain’t gonna access it … I ain’t gonna spread the word’ (Mclean et al., Reference Mclean, Campbell and Cornish2003; p. 667).
Racially-minoritised people are not aware of what help is available for mental distress or what help would involve. There are difficulties in accessing help and inappropriate options can be offered, such as medication rather than talking therapy. There are also barriers in the form of services not being accessible in terms of language. A female Asian participant said: ‘As a student who is a recent immigrant, my understanding of English is improving daily. As a result, sometimes I struggle to articulate clearly and accurately what I would like to say to the healthcare professionals provided at university. For this reason, I prefer not to discuss my psychological issues as they will misjudge what I am saying and then heavily medicate me’ (Arday, Reference Arday2018; p. 14).
If alternative support options are offered to racially-minoritised people, these may not be feasible due to financial constraints. This raises the question as to those people in higher socioeconomic groups being able to afford alternative therapeutic options, compared with those who are minoritised: ‘You know, you can’t access alternative therapies unless you’ve got the finances, and then you’ve got to remember that the sort of economic circumstances of a lot of African-Caribbean communities is disadvantaged. So, knowledge of the alternatives might be there, but access to them isn’t’ (Mclean et al., Reference Mclean, Campbell and Cornish2003; p. 667).
Services must build up trust in their ability to support people, as confidentiality and the need for safe spaces are essential to remove barriers in access. A Pakistani woman states: ‘You know that whole thing I said to you that about erm, not having people from outside come and know your business. That’s the whole, that’s whole izzat [honour] thing as well. You know, to, not, to not air your dirty laundry in public’ (Gunasinghe et al., Reference Gunasinghe, Hatch and Lawrence2019; p. 23).
Discussion
This review aimed to summarise qualitative empirical evidence related to the question: what are the barriers to mental health support for racially-minoritised people within the UK? This was not a comparison with White people’s experiences, as some of the findings may also relate broadly to the White population, such as stigma or being seen as ‘weak’ being barriers to help (Lynch et al., Reference Lynch, Long and Moorhead2018). This review was to better understand the barriers to support for people from different racially-minoritised communities, as relatively little is known in this area. Furthermore, it is important to hold in mind that papers were searched for throughout the UK; however, only papers in regions of England were found, highlighting the lack of research in other nations. The findings of this review will be summarised, considering CBT practice implications and discussion of the strengths and limitations.
‘Mental health’ is associated with stigma in wider society but also in an individual’s culture from the community or family, as there are negative associations with being ‘weak’ or a ‘failure’ (Shefer et al., Reference Shefer, Rose, Nellums, Thornicroft, Henderson and Evans-Lacko2013). There is also self-stigma with a sense of shame (Mantovani et al., Reference Mantovani, Pizzolati and Edge2016), a fear of disclosure due to what others in the community may think, and a fear of being isolated from the family or wider community (Islam et al., Reference Islam, Rabiee and Singh2015). It can be thought about how the term ‘mental health’ is constructed in the West and this is not the ‘norm’ in other non-Western cultures, with the experiences of emotions related to mental distress often not being spoken about (Arday, Reference Arday2018). There is less awareness in what mental health support is available for racially-minoritised people, with there being a lack of relatable and visual promotion (Sancho and Larkin, Reference Sancho and Larkin2020). Stigma is a key factor at individual and wider societal/cultural levels which would stop a person from reaching out for help.
Intersectionality of aspects of identity (such as age, race, gender, religion and class) was clear in how people from racially-minoritised communities within England understand, experience and cope with mental distress. For example, culture naturally impacts every aspect of illness, such as responses to symptoms, explanations, patterns of coping, help-seeking, adherence to treatment, and emotional expression. There are cross-cultural differences with how depression presents, such as somatic symptoms acting as cultural expressions of distress and feelings of guilt and suicide rates varying across culture. Depression may therefore be under-diagnosed, due to these variations and how they may not match-up to Western diagnostic criteria (Aichberger et al., Reference Aichberger, Schouler-Ocak, Rapp and Heinz2008; Bhugra and Mastrogianni, Reference Bhugra and Mastrogianni2004). Therefore, it is essential to consider the lens of each individual and how this influences their experiences and expression, to focus on their goals rather than rigid diagnostic set treatment methods.
A common theme was how there are expectations within each community to keep problems within the home or to oneself, with more value placed on ‘informal’ support structures such as family or friends (Shefer et al., Reference Shefer, Rose, Nellums, Thornicroft, Henderson and Evans-Lacko2013). There are spiritual coping methods people turn to, such as religious leaders in the form of pastors within the African Christian population (Mantovani et al., Reference Mantovani, Pizzolati and Edge2016). There is a difference with how help is understood in the West in the form of mental health professionals, but people find alternative sources of support such as through religion and family. It is important to highlight how some aspects of Western psychological therapy can be contradictory or incompatible with the values and cultural assumptions of individuals from non-Western cultures. It is therefore important to be competent in being guided by the individual, to avoid causing harm. An example of good practice of cultural adaptations in CBT comes from Jameel et al. (Reference Jameel, Munivenkatappa, Arumugham and Thennarasu2022) who used proverbs, local stories and simplified terminologies to facilitate positive outcomes with Indian clients. Therapists should be flexible and open to understanding the varying resources and sources of support people value and bring this into assessment, formulation and therapy.
From the review, racially-minoritised people tend to have a view of services as not being able to meet their needs (Rabiee and Smith, Reference Rabiee and Smith2013), with a need for a safe and understanding space (Shefer et al., Reference Shefer, Rose, Nellums, Thornicroft, Henderson and Evans-Lacko2013). People have felt discriminated against by professionals, being treated differently from White people (such as being offered medication rather than therapy; Memon et al., Reference Memon, Taylor, Mohebati, Sundin, Cooper, Scanlon and De Visser2016). Professionals and services were seen to hold power that impact the outcomes for minoritised people, with common misunderstandings in communication (Sancho and Larkin, Reference Sancho and Larkin2020) and people fearing judgement from professionals (Arday, Reference Arday2018). There are common concerns about confidentiality, which show how important it is for services to be warm, inviting and trustworthy. Considering socioeconomic status, minoritised people said how alternative options or quicker routes may be harder to access due to financial barriers (Memon et al., Reference Memon, Taylor, Mohebati, Sundin, Cooper, Scanlon and De Visser2016). It should be considered if there are alternative support options that the NHS could offer or if private/charitable services could offer reduced rates for people who have a lower income. Therapists must also consider the discrimination minoritised people may have experienced in society but also within services and how this has affected them in the past and present. Therapists and managers must uphold an anti-racist ethos using a top-down and bottom-up approach, attending relevant CPD (continuing professional development), using self-practice/self-reflection and supervision to turn towards their own biases (Thwaites et al., Reference Thwaites, Bennett-Levy, Davis, Chaddock, Whittington and Grey2014).
This review looked at many different communities, but it is essential to remember that these communities cannot be grouped into one, as having the same needs. A ‘one-size-fits-all’ approach cannot be used, as each person will have their own experiences. The differences between communities are seen such as some people talking to faith leaders (Mantovani et al., Reference Mantovani, Pizzolati and Edge2016) but others perceiving it as being shameful to discuss issues outside of the household (Memon et al., Reference Memon, Taylor, Mohebati, Sundin, Cooper, Scanlon and De Visser2016). This is important: to acknowledge the unique context and experiences of individuals, especially by professionals within therapy. Considering how racially-minoritised people are less represented within Talking Therapies services with lower recovery rates (NHS Digital, 2020), therapists must do more to better support individuals, such as providing tailored culturally sensitive therapy (Faheem, Reference Faheem2023). Many healthcare settings expect people to come forward to access them, but we have seen barriers and inequalities continue to exist and perception is key. As the BAME Positive Practice guide (Beck et al., Reference Beck, Naz, Brooks and Jankowska2019) outlines, there must be more work done within communities to reach out and co-produce services, with easier access and positive experiences, which may be shared amongst communities to then recommend the service to others (Mclean et al., Reference Mclean, Campbell and Cornish2003).
Implications for clinical practice
Practitioners should recognise how difficult it is for racially-minoritised people to access support, considering the additional barriers faced. Within clinical practice, time should be given to consider intersectionality, hearing more about the individuals experience and the narrative around ‘mental health’ within their specific community accounting for age, gender, ethnicity, religion, and other aspects of identity. Time should be taken to understand the individual’s understanding of distress, being curious and building a genuine rapport. Distress should be normalised, whilst holding a safe and non-judgemental space. More promotion is also needed in the media with racially-minoritised people accessing mental health support and this being visible, to help consider ways to reduce the stigma that exists (Sancho and Larkin, Reference Sancho and Larkin2020); for example, service websites, posters, and leaflets with representation from different communities.
People understand mental distress differently based on areas of social difference, which may be visible/invisible, voiced/unvoiced (Social GRACES; Burnham, Reference Burnham and Krause2013). For example, spirituality and religion impact how people understand distress and their subsequent valued coping resources (such as religious leaders or prayer). The strengths of communities must be acknowledged and incorporated within psychological intervention, which may not always be seen as the ‘traditional’ approach (Beck et al., Reference Beck, Naz, Brooks and Jankowska2019). Furthermore, mental health services should link in with community religious leaders, considering collaboration to support the community to overcome stigma and offer support options. Overall, co-production is needed with the community to increase awareness and conversations about mental wellbeing, and the support options available. Here are some questions that therapists should consider:
Are there religious leaders in the community or place of work who can be consulted?
Can specialist CPD be sought focused on specific populations within the community?
What research is currently available in working with specific communities?
Can the therapist be active to find out more about religion/culture and thinking about how this can be incorporated into therapy?
With consent, would the individual benefit from a family member or friend being involved?
Specialised professional development, training and reflective spaces could raise awareness within teams and for professionals in the specific considerations when working with racially-minoritised people. The experiences of racism and discrimination from services reported by participants in this review is shocking. Clinicians should be able to sensitively discuss experiences of racism if this is important to the client, to validate and support them using written guidance, such as Williams et al. (Reference Williams, Holmes, Manzar, Haeny and Faber2023) who developed an evidence-based approach for treating stress and trauma due to racism. Services that feel unsafe or unsuitable to meet one’s needs are likely to have an impact on engagement in treatment and could reinforce negative views that are reported (Memon et al., Reference Memon, Taylor, Mohebati, Sundin, Cooper, Scanlon and De Visser2016). Considering how hard it is to take the initial step to access help, there is a danger that this can be traumatising for an individual and put them off accessing support again in the future. Much more effort is needed to restructure services in terms of diversity and culturally sensitivity of the workforce (Rae, Reference Rae2016). Services must continually support and include people from minoritised communities within the workforce, which could help in giving service users more autonomy of choice in who they see.
Clearer and accessible referral pathways must be available, for people to know what options are available for support. As highlighted by findings from Rabiee and Smith (Reference Rabiee and Smith2013) and Rae (Reference Rae2016), at the commissioning and community level, funding should be considered for smaller community services that are valued and more accessible for racially-minoritised populations. Making links with community and grassroots organisations is essential, with protected time to allow therapists to do this essential work. However, services must first be able to work effectively with the communities they serve, before inviting them to access their service. This is to avoid an increase in referrals but then people dropping out, due to harmful experiences with structures and practitioners who are not equipped to best support them. Responsibilities do not just lie with the client or therapist, but with all aspects of healthcare systems. The BAME Positive Practice Guide (Beck et al., Reference Beck, Naz, Brooks and Jankowska2019) indicates essential action at the service level, better engagement with communities and improved staffing with the use of an audit tool to monitor progress and areas to improve on for Talking Therapies services to offer culturally safe and effective care.
Strengths and limitations
Strengths of this review include how the qualitative findings help to further our understanding of the barriers that exist for racially-minoritised communities in accessing mental health support, bringing forward the voices and real-life experiences from the participants. A second reviewer (S.O’H.) was also used throughout the systematic review process to avoid bias. The second reviewer is a White Irish female and the main researcher (S.A.) is a South Asian British male, bringing different perspectives to the systematic review process. The thematic synthesis methodology by Thomas and Harden (Reference Thomas and Harden2008) was adapted and followed closely by the two researchers. This was conducted in a rigorous way, with transparency of the process providing context for each of the 15 studies.
The use of a mix of participants is a limitation with varying mental health services (e.g. primary care and secondary care which use a range of treatment approaches), as samples were not homogenous. Furthermore, across all studies there is variation in how the research was conducted and analysed. This means greater variation in the data and less generalisability and external validity, with findings reflecting English-speaking service users, community members, professionals, and others in England. Furthermore, it is important to emphasise that all racially-minoritised populations cannot be collated into one single group, although there is a shared position that racially-minoritised groups hold in the UK context, both socially and politically (Bhui et al., Reference Bhui, Warfa, Edonya, McKenzie and Bhugra2007), which is highlighted by this review. Considering the limited research in this area, research papers in different regions around England were only found, with a lack of research in Northern Ireland, Scotland and Wales. A broader search was needed, over 50 years; however, only papers from the last 25 years were found, which further puts a spotlight on the need for further research with specific minoritised communities and this to be a priority for researchers and clinicians. A recommendation is made for local Talking Therapies service leads to allocate protected time for this research to be undertaken and disseminated widely, whilst supporting researchers during the publication and dissemination process.
Future research
Research could look at barriers to mental health support for specific communities in focused mental health services, such as local Talking Therapies service sites. This will help to appreciate each community as their own, with their own needs and considerations on how services can better meet these individual needs. For example, Alam (Reference Alam2023) demonstrates specific research with British-Bangladeshi men. This would also increase generalisability of findings to specific populations and how best to target initiatives to reduce barriers to mental health support. This review focused on a UK-wide population; however, the papers found were only those conducted around England. More focused research is needed in other UK nations such as Scotland, Wales and Northern Ireland with specific racially-minoritised populations that reside in these areas. It would also be useful to explore what barriers exist in other countries due to the international variation in healthcare. A final suggestion could be looking at the needs of staff and Talking Therapies services to better meet the needs of the populations they serve (e.g. adaptations to CBT).
Conclusion
This review aimed to summarise and synthesise qualitative research evidence looking at the barriers to mental health support for racially-minoritised people within the UK. The findings show that there are multiple barriers such as stigma, understanding of distress and coping, lack of competence of teams, how or if services are perceived and the access barriers. Further research is needed, looking at how the needs of specific racially-minoritised people can be better met, not only at the individual level but within the community, services, and also on a wider more political and social level (Shade, Reference Shade2021).
Essentially, there is a need to continue striving for inclusive and improved healthcare provision for all. This systematic review and thematic synthesis leaves the reader to consider how ‘mental health’ is constructed across different populations, what barriers exist to access care such as Talking Therapies services, but also where these barriers are located, which may not always be acknowledged. The answer is not only to remove barriers, but services and therapists must also turn inwards to address their gaps, biases and be flexible in how communities are supported. This is essential to avoid harm to racially-minoritised service users and staff who step into services which must be equipped to offer support sensitively and safely. Consider what changes can be made in the context you are in, and what further research is needed to indicate action to better support racially-minoritised individuals.
Key practice points
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(1) Talking Therapies services and therapists must embody an anti-racist ethos to improve the care of racially-minoritised communities. Gaps in skill and knowledge must be identified, to continuously access quality CPD, reflective spaces and supervision (e.g. cultural adaptations or having sensitive discussions related to the experiences of racism).
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(2) More research needs to be done looking at the mental health needs of specific communities and how to work in different ways to meet these needs in culturally sensitive ways (e.g. consider intersectionality; linking culture and religion into therapy). Service leads must prioritise research and support staff during the process, from conception to dissemination.
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(3) Once Talking Therapies services are better able to support minoritised communities, services must become more accessible. Some suggestions include improved referral pathways, visible promotion, and referrers (such as GPs) keeping therapy in mind for everyone.
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(4) Talking Therapies services must diversify the workforce to increase representation of different communities and to give people choices in who they therapeutically work with. Racially-minoritised staff must be continually supported.
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(5) Professionals must do more outreach work in the community and collaborate with service users and grassroots organisations to remove barriers to access (e.g. stigma) and co-produce services.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S1754470X24000084
Data availability statement
Data availability is not applicable to this article as no new data were created or analysed in this study. The primary researcher Dr Shah Alam can be contacted should further information be needed regarding this systemic review.
Acknowledgements
Colleagues within the BABCP Anti-racism SIG (formerly Equality & Culture) helped support this research and contributed to many of the references cited.
Author contributions
Primary author Dr Shah Alam led in conceptualising the review question and all stages of the research and write-up. Dr Alex Fowke contributed to drafting and revising the review, and Sophie O’Halloran contributed to the analysis and interpretation of data. Both co-authors reviewed the final submission of the paper.
Shah Alam: Conceptualization (lead), Data curation (lead), Formal analysis (lead), Investigation (lead), Methodology (lead), Project administration (lead), Writing – original draft (lead), Writing – review & editing (lead); Alex Fowke: Formal analysis (supporting), Supervision (supporting), Writing – original draft (supporting), Writing – review & editing (supporting); Sophie O’Halloran: Data curation (supporting), Formal analysis (supporting), Methodology (supporting), Writing – review & editing (supporting).
Financial support
This research was completed in 2021 as part of a Doctoral thesis for Clinical Psychology training in the UK at Royal Holloway, University of London. Training is funded by the National Health Service (NHS) and Higher Education England (HEE). Otherwise, this research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The authors declare none.
Ethical standards
The authors have abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the BABCP and BPS.
Appendix – Additional quotes to support the themes
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